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Multimodal analgesia for management of postoperative pain

Multimodal techniques for pain management include administration of two or more drugs that act by different mechanisms for providing analgesia. The drugs may be administered via the same or by different routes ASA Section V, p 253.

The aim of ‘balanced’ or ‘multimodal’ analgesia is to reduce pain scores and\or reduce the dose of medications, particularly with regard to opioids (=’opioid sparing effect’) and thus, reduce the frequency or severity of adverse effects French, section 6, p 405. ASA Section V, p 254.

Treatment specific perioperative issues

Multimodal techniques can be used with central regional blockade with local anaesthetics or with systemic analgesics. ASA section V.p253

The choice of analgesics, dose and route should depend on the type of surgery and patient characteristics ASA Section V, recommendations.

Dosing regimens should optimize efficacy while minimizing the risk of adverse effects. ASA Section V, recommendations

Examples of multimodal treatment protocols recommended by PROSPECT for colon surgery,non-cosmetic breast surgery or laparoscopic cholecystectomy

Epidural analgesia can fail for a variety of reasons. In a large audit, 22% of patients had premature termination of postoperative epidural infusions. This reinforces the need for multimodal analgesia as a compliment or alternative to epidural analgesia ANZCA chapter 7, ‘Treatment failure’ p 189.

Multimodal systemic regimens

  • Combine at least one non-opioid with morphine. French section 6, p 406
  • COX-2 selective NSAIDS, non-selective NSAIDs and calcium channel α-2-δ anatogonists (gabapentin and pregabalin) should be considered as part of a multimodal treatment regimen ASA section V, p 254 andunless contraindicated, patients should receive COXIBs, NSAIDs or paracetamol on an around the clock regimen ASA Section V, p 254
  • PROSPECT recommends to combine paracetamol with a non-specific NSAID or COXIBs for low to moderate pain. However, particularly in the case of high-risk patients, paracetamol is a viable alternative to NSAIDs, especially because of the low incidence of adverse effects. It may be appropriate to combine paracetamol with NSAIDs, but future studies are required, especially after major surgery, with specific focus on a potential increase in side-effects from their combined use ANZAC Chapter 4, ‘Efficacy’, page 72.
  • Gabapentin, non-specific NSAIDs and ketamine are opioid sparing medications and reduce opioid-related side effects. ANZCA Chapter 4, p 70.
  • While multi-modal analgesic regimens can provide good analgesia, opioid tolerant patients are at risk of withdrawal if treated with a non-opioid analgesic multimodal regimen or one that employs tramadol. ANZCA Chapter 11, ‘Prevention of withdrawal’ p 426.

Circumstances when the treatment is not recommended:

Multimodal analgesia should follow contraindications of each component of the combined treatment.

The use of multiple analgesic drugs will add to the cost of the treatment of each drug and the nursing time related to preparation, administration and monitoring.


Multimodal analgesia consists of combining two or more analgesics, given via the same or by different routes. The aim of this treatment technique is to improve analgesia, and\or reduce opioid requirements and consequently to reduce opioid related side effects. A commonly used regimen is to combine non-opioid analgesics with an opioid. Use multi-modal techniques whenever possible.

Supplementary reading:

  1. De Oliveira GS et al. Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials.Anesth Analg. 2012 Feb;114(2):424-33.
  2. Maund E, et al. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth. 2011 Mar;106(3):292-7.
  3. Rawlinson A, Kitchingham N, Hart C, McMahon G, Ong SL, Khanna A. Mechanisms of reducing postoperative pain, nausea and vomiting: a systematic review of current techniques. Evid Based Med. 2012 Jun;17(3):75-80.
  4. Rømsing J, et al. Reduction of opioid-related adverse events using opioid-sparing analgesia with COX-2 inhibitors lacks documentation: a systematic review. Acta Anaesthesiol Scand. 2005 Feb;49(2):133-42.